Just Culture Algorithm

Florida resident David Marx invented the Just Culture Algorithm™ for the Just Culture Company, which is part of Outcome Engenuity, of which Marx is CEO. The business has been in existence since the 1990s. Marx has worked to create safer environments for businesses in a range of sectors, from the medical world to nuclear power, and even NASA. 

The Just Culture Algorithm is a valuable tool that helps entities establish a non-punitive approach to patient safety, incorporating core concepts described below. The algorithm may be applied to realized errors or near-miss events alike. The algorithm asks a series of questions that help administrators and staff identify areas for system optimization. Before applying the algorithm: 

A. Ask the following questions: 

1. What happened? 

2. What normally happens? 

3. What does procedure require (if applicable)? 

4. Why did it happen?

 5. Is our system currently set up to prevent these types of events? If so, what is in place to prevent these types of errors? 

B. Apply the following tests: 

1. Substitution test: Would a competent employee with the equivalent level of training have done the same thing? Would you have committed the same error? 

2. Test of intention: Did the employee knowingly violate standards of care? 

3. Impaired practices: Was the employee impaired due to substance abuse or health issue? 

“the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes” -jointcommision.org.